Study adds to evidence but mechanism remains unclear

AMSTERDAM -- HIV is an independent risk factor for heart failure, a researcher said here.

A large database analysis, involving more than 425,000 people, suggested that HIV leads to at least a 66% increase in the risk of heart failure compared with the risk for people without HIV, according to Alan Go, MD, of the Kaiser Permanente Division of Research in Oakland, Calif.

But exactly why the risk rises remains an open question, although investigators were able to rule out some potential contributing factors, Go reported at the International AIDS Conference.

It's the second large study recently to report a link between HIV and heart failure; in 2017 researchers looking at about 98,000 U.S. veterans reported they found a 41% increased risk for people with the virus.

"There are more and more studies looking at heart failure and HIV, although not at as large as this," commented Priscilla Hsue, MD, of the University of California San Francisco, who was not part of the study but who co-moderated the oral session at which it was presented.

"I think what this study doesn't touch on -- which they're looking at -- is why," she added. "Is it traditional risk factors, is it HIV medication, or is it the HIV itself?"

The take home message for doctors, Hsue told MedPage Today, is that "there's a high risk of heart failure in the setting of HIV and clinicians should be really aware of it."

Go noted that heart failure is highly prevalent around the world, with some 26 million people suffering from it, include roughly 6 million in the U.S. At the same time, HIV infection affects about 34 million people worldwide and 1.1 million in the U.S.

HIV infection is known to increase atherosclerotic cardiovascular disease, he added, but there is limited data about the possible link between heart failure and the virus. To help clarify the issue, he and colleagues turned to the medical records of three Kaiser Permanente health delivery systems, in Northern and Southern California and the Mid-Atlantic states.

The investigators looked for people with HIV but with no previous heart failure enrolled in any of the systems between 2000 and 2016 and matched each with 10 HIV-negative patients, also without prior heart failure. The matching was based on year or entry into the system, age, sex, race, and primary treating facility.

All told, Go said, they analyzed data for 38,868 people with HIV and 386,586 without.

The rate of incident heart failure was 0.24 cases per 100 person-years among those with HIV, compared with 0.16 among those who were HIV-negative. The difference was highly statistically significant, he said.

In multivariate analyses, the investigators adjusted for demographic characteristics, cardiovascular, and medical history, as well as the use of cardiopreventive medication, diabetes therapy, and non-steroidal anti-inflammatories.

In the fully adjusted model, the hazard ratio for heart failure was 1.75. A further adjustment to take into account acute coronary syndrome events during follow-up attenuated the association to a hazard ratio of 1.66.

There are several possible mechanisms, Go said, including direct HIV damage to the myocardium, autoimmune or inflammatory myocarditis, or toxic and infectious myocarditis.

The study was large and multi-institutional, with a geographically and ethnically diverse population, Go said, and the researchers were able to study potential confounders and explanatory variables through comprehensive electronic health records.

The use of electronic health records allowed the investigators to conclude that the heart failure "does not appear mediated through atherosclerotic disease pathways or differential use of cardiopreventive medications," he reported.

He cautioned that the study only reflects an American population receiving health care.

The study had support from the National Heart Lung and Blood Institute. Go is an employee of Kaiser Permanente. He said he had no relevant disclosures.

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